Urinary Tract Infections in Renal Transplant Recipients

J. Gołe˛biewska, A. De˛bska-Ślizień, J. Komarnicka, A. Samet, and B. Rutkowski

ABSTRACT
Introduction. Urinary tract infections (UTIs) are most common infections in renal
transplant recipients and are considered a potential risk factor for poorer graft outcomes.
Aim. To evaluate incidence, clinical manifestations, microbiology, risk factors for UTIs,
and the influence of UTIs on long-term renal graft function.
Patients and methods. We analyzed urine cultures with reference to clinical data of
patients who received a renal transplantation from January to December 2009 with a
12-month follow-up.
Results. The 1170 urine cultures were correlated with clinical data from 89 renal
transplant recipients, including 58.4% males and on overall mean age of 48 ⫾ 14 years. The
151 episodes in 49 patients consisted of asymptomatic bacteriuria (65%, n ⫽ 98); lower
UTIs (13%, n ⫽ 19); and upper UTIs (22%, n ⫽ 34), as well as five cases of bacteremia.
Nearly 48% of UTIs were diagnosed during the first month posttransplantation. The most
frequently isolated uropathogens were Enterococcus faecium (33%, n ⫽ 24) and Esche-
richia coli (31%, n ⫽ 23). Beginning from the second month, most frequently found
bacterium in urine cultures was E coli (65% n ⫽ 51). Risk factors for posttransplant UTIs
were female gender and a history of an acute rejection episode and/or a cytomegalovirus
(CMV) infection. All patients with vesicoureteral reflux of strictures at the ureterovesical
junction suffered recurrent UTIs (n ⫽ 7). The evolution of renal graft function did not
differ significantly between patients with versus without UTIs.
Conclusions. UTIs a frequent problem after kidney transplantation most commonly exist as
asymptomatic bacteriuria. E coli and E faecium are ther predominant pathogens. Exposure to
intensified immunosuppression due to acute rejection episodes or CMV infections represents
a risk factor for UTIs. Vesicoureteral reflux or strictures at the ureterovesical junction are risk
factors for recurrent UTIs. UTIs did not impair 1-year graft function.

HEALTHY PERSON’S URINARY TRACT is pro-
A tected against infections by a variety of nonimmuno-
logic and immunologic mechanisms that are not fully
efficient in renal transplant (RTx) patients. Apart from
immunodeficiency resulting from immunosuppression, RTx
patients often suffer from various urologic malformations as
well as postoperative vesicoureteral reflux and are exposed
to invasive diagnostic and therapeutic procedures. Thus
urinary tract infections (UTIs) are the most common
infectious complication with up to a 60% prevalence during
the first year posttransplantation.1
UTIs are important not only because they are wide-
spread, but they also represent a potential risk factor for
poorer graft and recipient outcomes. Infections, with the
urinary tract as a major site, are most common cause of
acute kidney allograft injury. The prevalence of infection-
related renal impairments far outnumbers episodes of acute
rejection and calcineurin inhibitor toxicity.2
From the Department of Nephrology, Transplantology and
Internal Medicine, (J.G., A.D.-S., B.R.) Medical University of
Gdańsk, Gdańsk, Poland; Department of Epidemiology (J.K.),
Medical University of Gdańsk Clinical Center, Gdańsk, Poland;
and Laboratory of Clinical Microbiology (A.S.), University Centre
for Laboratory Diagnostics, Medical University of Gdańsk Clini-
cal Centre, Gdańsk, Poland.
Address reprint requests to Justyna Gołȩbiewska, Department
of Nephrology, Transplantology and Internal Medicine, Medical
University of Gdańsk, ul. De˛binki 7, 80-952 Gdańsk, Poland.
E-mail: igolebiewska@gumed.edu.pl

© 2011 by Elsevier Inc. All rights reserved. 0041-1345/–see front matter

360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2011.07.010

Transplantation Proceedings, 43, 2985–2990 (2011) 2985

2986
Reports on the influence of UTIs on long-term kidney
allograft function are inconsistent. Pellé et al showed that
acute graft pyelonephritis (AGPN) was an independent risk
factor for the decline in renal function among 172 recipi-
ents.3 However, other reports did not confirm this relation-
ship.4 – 6 Even if UTIs do not affect graft survival directly,
they can exert such an effect indirectly by leading to
bacteremia, acute rejection episodes, or cytomegalovirus
(CMV) infections.
There are also conflicting data on risk factors for UTIs
among recipients. It seems crucial to identify patients most
susceptible to UTIs, especially recurrent, symptomatic in-
fections, and to note the most effective prophylaxis and
treatment measures for empirical therapy. Therefore, the
aim of the study was to evaluate incidence, clinical mani-
festations, microbiology, risk factors, and the influence on
long-term renal graft function of UTIs.
PATIENTS AND METHODS
We performed a retrospective cohort study reviewing the medical
records of patients who received renal transplantations from
January 1, to December 31, 2009. The five patients who transferred
to other transplantation centers at 1 month after transplantation
were excluded from the analysis. We analyzed urine cultures with
reference to clinical data. We compared demographic features and
clinical data of patients without versus with UTIs, considering the
etiology of end-stage renal disease, age, sex, comorbidity (esti-
mated with the use of Charlson Comorbidity index), prior recurrent
UTIs dialysis type, pretransplant dialysis time, repeated transplan-
tation, acute rejection episodes (ARE), acute tubular necrosis
(ATN), delayed graft function (DGF), use of a double-J ureteral
stent, type of immunosuppression (cyclosporine [CsA] tacrolimus
[tac], everolimus, mycophenolate mofetil [MMF]/sodium [MPS]),
induction therapy with monoclonal (basiliximab) or polyclonal
antibodies (antithymocyte globulin [ATG] and CMV infections. To
assess renal allograft function, we used serum creatinine concen-
trations and MDRD-estimated glomerular filtration rate (eGFR)
at 1, 3, 6, 9, and 12 months posttransplant.
Immunosuppressive Treatment
All patients initially underwent induction with monoclonal (basil-
iximab) or polyclonal antibodies (ATG) and were prescribed
subsequently tac ⫹ MMF MPS ⫹ glucocorticosteroids or CsA ⫹
MMF/MPS ⫹ glucocorticosteroids or CsA ⫹ everolimus ⫹ gluco-
corticosteroids. The treatment of acute rejection consisted of
intravenous glucocorticosteroid bolues for 5 consecutive days,
followed by a course of ATG in cases of glucocorticoid resistance.
Prophylaxis for Infections
The hospital’s epidemiologist, recommended that all patients re-
ceive ceftriaxone perioperatively usually for 7 to 10 days as it takes
account of current antibiotic resistance of Gram-negative strains.
In cases of donor positive cultures, the antibiotic was chosen
according to the susceptibility profile. A urethral catheter inserted
perioperatively was removed between day 4 and 7 posttransplan-
tation, while the double-J ureteral stent was removed at 4 to 6
weeks. Recurrent UTIs were considered an indication for prema-
ture double-J ureteral stent removal. All patients received 480 mg
of trimetoprim/sulfamethoxazole daily for 6 months. Patients were
GOŁE˛BIEWSKA, DE˛BSKA-ŚLIZIEŃ, KOMARNICKA ET AL
also educated to drink a lot of fluids and urinate frequently.
Patients were also on vitamin C and either methylene blue or
cranberry preparations.
Definitions of UTIs
All UTIs were classified into one of four following categories: (1)
asymptomatic bacteriuria (AB), (2) lower UTI, (3) upper UTI
(AGPN) or (4) urosepsis. Asymptomatic bacteriuria was defined as
isolation of bacterial strain in quantitative counts ⱖ105 colony-
forming units (CFU) in a clean-catch voided urine specimens in the
absence of any symptoms of lower or upper UTI (including
leukocyturia). In women the result had to be documented in two
consecutive specimens, the second obtained at least 24 hours later.
The presence of ⬍105 CFU in avoided sample from a patient or
ⱖ102 CFU in a single catheterized urine specimen was treated with
antibiotics. Lower UTIs were diagnosed in the presence of bacte-
riuria and clinical manifestations of dysuria, frequency, or urinary
urgency and fever ⬍ 38°C in the absence of AGPN criteria. Upper
UTI was defined by the presence of significant bacteriuria, fever
⬎38° and/or graft pain and/or acutely impaired graft function. The
diagnosis of urosepsis was made when simultaneous positive blood
and urine cultures were obtained with the isolation of the same
bacterial strain.
UTIs were classified as a new infection, a relapse, or a reinfec-
tion. Relapse was defined as the isolation of the same microorgan-
ism that caused the preceding infection in a urine culture obtained
ⱖ2 weeks after finishing the previous treatment. Reinfection was
defined by a new episode of UTI with the isolation of an agent
other than the one that caused the previous infection.
Cases of AB were considered cured after obtaining two consec-
utive negative urine cultures. In symptomatic UTIs an additional
criterion was complete resolution of clinical and laboratory symp-
toms.
Antibiotic Treatment
Every diagnosed UTI episode was treated with antibiotics including
cases of AB. For AB the antibiotic chosen according to the
susceptibility profile was administered for 7 to 14 days. In symp-
tomatic infections empirical treatment was initiated usually with
amoxicilline-clavulanate or ciprofloxacin and then changed accord-
ing to the susceptibility profile unless clinical response to initial
treatment was satisfactory. In lower UTIs, treatment lasted 7 to 14
days, while in upper UTIs, at least 14 days.
Statistical Analysis
All analyses were performed using Statistica 9.0 (StatSoft) soft-
ware. Two-tailed Student unpaired t test were used to compare
continuous variables and ␹2 tests for proportions. To assess the
significance of changes in renal graft function we employed two-
way analysis of variance for repeated measures. Logistic regression
analyses were performed to identify independent risk factors for
UTIs. Statistically significant variables in the univariate analysis
were introduced into a multivariate model based on forward
stepwise logistic regression. Associations are given as odds ratios
with 95% confidence intervals. P ⱕ .05 was considered to be
statistically significant.
RESULTS
We analyzed demographic and clinical data together with
urine cultures among 89 RTx recipients including 37
URINARY TRACT INFECTION IN RENAL RECIPIENTS 2987

women and 52 men of overall mean age of 48.13 ⫾ 13.85
years and mean dialysis treatment of 26 ⫾ 26 months. The
etiologies of end-stage renal failure were: primary glomer-
ulonephritis (n ⫽ 28; 31.5%), autosomal-dominant polycys-
tic kidney disease (n ⫽ 16; 18%), diabetic nephropathy (n ⫽
12; 13.5%), hypertensive nephropathy (n ⫽ 10; 1.2%),
tubulointerstistial nephritis (n ⫽ 8; 9%), lupus nephritis
(n ⫽ 1; 1.1%), other causes (n ⫽ 2; 2.2%), or unknown
etiology (n ⫽ 12; 13.5%). Only 11 patients underwent a
second RTx. In contrast to 69 (78%) patients on mainte-
nance hemodialysis (MHD) before transplantation, 20
(22%) underwent chronic peritoneal dialysis (CPD), while
nine patients had been treated consecutively with MHD
and CPD, and nine patients underwent preemptive trans-
plantation (10%). All patients received grafts from de-
ceased individuals, apart from only one from a living related
donor. There were 60 subjects on tac, 29 on CsA, 85 on
MMF/MPS, and 4 on everolimus. All patients were main-
tained on glucocorticosteriods. Induction with ATG was
used in six and basiliximab in five patients. A double-J
ureteral catheter was placed in 59 cases. Thirtyfour (38%)
patients had DGF and 14 (16%) ATN. Twentyseven (30%)
patients were diagnosed with an ARE (not biopsy proven)
and 26 (29%) developed CMV infections.
During the observation period we performed 1170 urine
cultures: 681 during the first month and 315 between 2 and
12 months. Among them 858 (73%) were negative; 79
contaminated; and 233 (20%) positive with 14.6% positive
for two bacterial species.
Among the 49 patients diagnosed with 151 UTI episodes,
nearly half occurred during the first month posttransplant
with 65% AB (n ⫽ 98); 13% lower UTIs (n ⫽ 19); 22%
upper UTIs (n ⫽ 34); and five cases of bacteremia. At least
one UTI was demonstrated in 49 patients: 16 subjects had
one; 9, two; 2, three; 14, four; 4, five; 1, six; 3, seven; and 1,
eight UTIs. Among 16 patients with only one UTI, it was
symptomatic only in six. Among 33 patients with recurrent
infections, only six were consecutive episodes of AB; the
other 27 patients suffered at least one symptomatic UTI.
The most frequently isolated pathogens were Escherichia
coli (n ⫽ 30), Enterococcus faecium (n ⫽ 30), Klebsiella spp
(n ⫽ 12), and Proteus spp (n ⫽ 9). E. coli was the
causative agent in 21/29 upper UTIs without bacteremia.
E coli was isolated in 4/5 cases of bacteremia; in one case
it was Klebsiella pneumonia. We isolated highly resistant
strains in 30 cases: extended-spectrum beta-lactamase
(ESBL) producing Enterobacteriaceae (n ⫽ 26), high level
of aminoglicoside-resistant Enterococci or vancomycin-
resistant E faecium (n ⫽ 4). There were four cases of
fungal UTIs, all in the first month posttransplant and
caused by Candida spp.
The etiology differed between the early and late periods
after RTx. In the first posttransplant month, E faecium
predominanted (33%, n ⫽ 24), followed by E coli and E
faecalis. Beginning from the second month E coli was the
most frequently isolated causative agent (65%, n ⫽ 51),
followed by Klebsiella spp and Proteus spp.
The demographic and clinical features of patients with
versus without UTI are presented in Table 1 On univariate
analysis, factors significantly associated with UTIs were
female gender, history of ARE, and CMV infection. How-
ever, female gender was the only independent predictor
upon multivariate analysis. No significant risk factors were
determined among immunosuppressive drugs, including the
use of induction regimens. Placement of a double-J ureteral
catheter also did not increase the likelihood of acquiring

Table 1. Demographic and Clinical Features of the Groups

Variable, n (%) UTI⫹ (n ⫽ 49) UTI⫺ (n ⫽ 40) P

Age (y) 48.5 ⫾ 14.33 47.64 ⫾ 13.4 .77

Gender (F/M) 30/19 (61.22%/38.78%) 7/33 (17.5%/82.5%) ⬍.001
Comorbidity (CCI) (points) 4.38 ⫾ 1.93 4 ⫾ 1.81 .35
Recurrent UTIs before RTx 6 (12.24%) 2 (5%) .23
HD before RTx 35 (71.43%) 34 (85%) .13
PD before RTx 12 (24.49%) 8 (20%) .61
Dialysis vintage before RTx (mo) 24.92 ⫾ 23.99 27.31 ⫾ 28.59 .67
Second RTx 6 (12.5%) 5 (12.24%) .23
ARE 22 (44.9%) 7 (17.5%) .006
ATN 7 (14.58%) 7 (17.5%) .71
DGF 19 (38.78%) 15 (37.5%) .9
Double-J catheter 32 (65.31%) 27 (67.5%) .83
CsA 15 (30.61%) 14 (35%) .66
Tac 33 (67.35%) 26 (65%) .82
MMF/MPS 47 (95.92%) 38 (95%) .83
ATG 5 (10.2%) 1 (2.5%) .15
Basiliximab 3 (6.1%) 2 (5%) .81
Induction (either ATG or basiliximab) 8 (16.3%) 3 (7.5%) .21
CMV infection 20 (40.82%) 6 (15%) .007
RTx, renal transplantation; CCI, Charlson Comorbidity Index; HD, hemodialysis; PD, peritoneal dialysis; ARE, acute rejection episode; ATN, acute tubular necrosis;
DGF, delayed graft function; CsA, cyclosporine; Tac, tacrolimus; MMF/MPS, mycophenolate mofetil/sodium; ATG, antithymocyte globulin; CMV, cytomegalovirus;
UTI, urinary tract infection.
2988 GOŁE˛BIEWSKA, DE˛BSKA-ŚLIZIEŃ, KOMARNICKA ET AL

UTI (Table 1). In 21/32 patients who developed UTI with a
double-J stent, there were subsequent infections after re-
moval of the double-J. Another four patients developed
their first UTI episodes after removal of the double-J. All
patients with vesicoureteral reflux or strictures at the uret-
erovesical junction suffered recurrent UTIs (n ⫽ 7); 3/5
cases of urosepsis diagnosed in one patient with a stricture
at the ureterovesical junction were caused by ESBL E coli.
Patients with no episodes of asymptomatic bacteriuria
developed significantly fewer symptomatic infections than
those with a history of recurrent AB. There were 55%
reinfections among recurrent UTIs. In patients with a
history of recurrent AB, the number of reinfections and
relapses did not differ significantly. In patients with vesi-
coureteral reflux or strictures at the ureterovesical junction,
relapses accounted for 70% of recurrent infections.
Upper UTIs were accompanied by a significant rise in
creatinine level. However, 12-month follow-up failed to
show any UTI, an upper UTI or a symptomatic UTI to exert
any effect on renal graft function measured by creatinine
level of eGFR (Tables and 1 and 2).
DISCUSSION
UTIs with a 55% incidence in this study represent a
common complication after RTx. AB, the prevailing form
accounted for 65% of all diagnosed UTIs. There was an
increased number of symptomatic infections in the later
period after transplantation; only 18% occurred during the
first month and 35% throughout the study period. Only 2%
of UTIs were accompanied by bacteremia, mostly E coli.
Nearly half of the UTIs were diagnosed during the first
month posttransplantation. The most frequently isolated
uropathogen at this time was E faecium. Beginning from the
second month, the bacterium most frequently found in
urine cultures was E. coli. Risk factors for posttransplant
UTIs upon univariate analysis were female gender and a
history of ARE and/or CMV infection. All patients with
vesicoureteral reflux or strictures at the ureterovesical
junction suffered recurrent UTIs. Patients with recurrent
AB were more prone to develop symptomatic infections.
Even though upper UTIs caused a significant raise in
creatinine level, the evolution of renal graft function during
the 1-year observation period did not differ significantly
between patients with versus without UTIs.
The reported incidence of UTIs varies from 36%7 to
60%1. The incidence is lower when cases of AB are
excluded from the analysis. In the recent study by Fiorante
et al, UTI were diagnosed in 52.9% of 189 deceased donor
recipients over a 3-year observation, with an many as 85%
being AB cases. The authors performed a urine culture in
each patient during every medical visit regardless of symp-
toms, history of recurrent UTIs, and time from RTx.8 The
high incidence of AB in the latter study and in our
observation most probably resulted from close surveillance
and a large number of cultures. So far there are recommen-
dations for screening and treatment of AB in renal trans-
plant recipients, because evidence-based data are lacking.9
Similarly to Fiorante et al, we treat all AB cases, which
perhaps explains the low percentage of symptomatic UTIs
during the first month posttransplantation at our center. On
the other hand, the above-mentioned investigators showed
a significantly higher incidence of AGPN among patients

Table 2. Univariate and Multivariate Analysis of Risk Factors Associated With the Occurrence of UTIs
Univariate Analysis, Multivariate Analysis
Variable, n (%) OR (95% CI) P OR (95% CI) P

Age (y) 1.00 (0.97–1.04) .76 — —

Gender (F/M) 7.44 (2.71–2.48) ⬍.001 6.18 (2.14–17.86) ⬍.001
Comorbidity (CCI) (points) 1.12 (0.89–1.41) .33 — —
Recurrent UTIs before RTx 2.65 (0.49–14.26) .25 — —
HD before RTx 0.44 (0.15–1.3) .14 — —
PD before RTx 1.3 (0.46–3.62) .61 — —
Dialysis vintage before RTx (mo) 1.00 (0.98–1.01) .71 — —
Second RTx 0.73 (0.26–2.06) .55 — —
ARE 3.84 (1.41–10.49) .009 2.27 (0.73–7.03) .15
ATN 0.80 (0.25–2.57) .71 — —
DGF 1.06 (0.44–2.52) .9 — —
Double-J catheter 0.91 (0.37–2.22) .83 — —
CsA 0.82 (0.33–2.02) .66 — —
Tac 1.11 (0.45–2.72) .81 — —
MMF/MPS 1.24 (0.16–9.46) .84 — —
ATG 4.43 (0.48–40.48) .19 — —
Basiliximab 1.24 (0.19–8.00) .82 — —
Induction (either ATG or 2.41 (0.58–9.95) .22 — —
basiliximab)
CMV infection 3.91 (1.36–11.2) .01 3.18 (0.99–10.26) .052
Rtx, renal transplantation; CCI, Charlson Comorbidity Index; HD, hemodialysis; PD, peritoneal dialysis; ARE, acute rejection episode; ATN, acute tubular necrosis;
DGF, delayed graft function; CsA, cyclosporine; Tac, tacrolimus; MMF/MPS, mycophenolate mofetil/sodium; ATG, antithymocyte globulin; CMV, cytomegalovirus;
UTI, urinary tract infection; OR, odds ratio; CI, confidence interval.
URINARY TRACT INFECTION IN RENAL RECIPIENTS
with a history of multiple AB episodes than those without
them despite the antibiotic treatment. In our study, patients
with no episodes of AB developed significantly fewer symp-
tomatic infections than those with a history of recurrent
AB. Because the number of relapses and reinfections was
similar among patients with a history of recurrent AB, this
condition may be a marker of increased susceptibility to
infections.
Our incidence of urosepsis was comparable to that
reported by other centers with E coli as the most frequently
isolated pathogen. A retrospective study by Silva et al in
more than 3300 RTx recipients showed as 4% incidence of
bloodstream infections with the urinary tract as the primary
source of infection in almost 40% of cases. E coli as the
most prevalent pathogen overall.10 E coli is the most
frequently isolated microorganism in urine cultures.7,11,12
However, Enterococccus spp have emerged as important
causative agents in RTx recipients.12,13 In a study by
Alangaden et al, Enterococccus spp accounted for 33% of
UTIs, but the authors failed to identify any specific risk
factor associated with the predominance of this uropatho-
gen.14 A possible explanation for the high number of
Enterococcus spp infections at our center is the routine use
of ceftriaxone for perioperative prophylaxis. This antibiotic
acts against Gram-negative bacilli, therefore promoting
selection of Enterococcus spp. However, it is difficult to
explain resistant E faecium which is usually susceptible only
to vancomycin and teicoplanin predominates, instead of E
faecalis that is susceptible to most antibiotics.
Several other authors have confirmed that female gender
appears to confer the strongest risk for UTIs.7,12,13 It seems
quite obvious and therefore requires no further comment.
Many authors have indicated that RTx recipients with a
history of ARE are at increased risk of an upper UTI
including urosepsis.7 ARE treatment may promote UTIs by
increasing net immunosuppression. However, some reports
have suggested that UTI triggers ARE.15 Kamath et al
reported that ARE preceded AGPN in 41% of cases and
followed AGPN in nearly 28% of cases10 We did not
analyze the time sequence of ARE and UTIs. CMV infec-
tion also increases net immunosuppression by weakening
host immune responses, therefore predisposing to other
infections. On the other hand, UTI reactivates latent CMV
virus as proinflammatory cytokines trigger CMV replica-
tion.
The influence of double-J catheter use on the risk of UTI
remains controversial. The results from both retrospective
observations6,16,17 and from randomized controlled trials
(RCT) are conflicting Giakoustidis et al, Mathe et al, and
Dominguez et al. observed no increase in UTI rates after
double-J use.16 –18 In an RCT of 201 RTx recipients Tava-
koli et al confirmed an association between double-J use
and UTIs, but only when the stent was remained lower than
30 days.19 Osman et al described an increased incidence of
UTIs among patients with a double-J insert, although the
stents were removed after 2 weeks.20 We failed to observe
an association. In our patients, double-J catheters were
2989
removed between 4 and 6 weeks after transplantation
unless it fell out spontaneously or there were recurrent
fonts of infections. Despite this, in 2/3 of patients with
double-J stents who developed UTI, there were subsequent
infections after the double-J removal. Four patients devel-
oped their first episodes of UTI after the removal of
double-J. Hence, it seems that other factors determine
susceptibility to UTIs. Nevertheless, the use of ureteral
stents may increase the likelihood of acquiring an UTI in a
patient with other multiple risk factors.
The influence of UTIs on renal graft function has not
been well elucidated; benign UTI such as AB and lower
UTI appear to not influence glomerular filtration rates. To
date, there is no consensus regarding the influence of
AGPN on long-term graft function and survival. Pellé et al
observed a decreased eGFR at 1 year after an episode of
AGPN compared with RTx recipients without UTIs and
those with lower UTIs. This discrepancy persisted during
4-year follow-up.3 Giral et al reported that only AGPN
within first 3 months posttransplantation exerted a negative
effect on graft survival.5 In a study by Kamath et al, most
episodes of AGPN were reported within first 3 months after
RTx; still they did not affect graft survival.6 Fiorante et al
demonstrated that levels of serum creatinine, creatinine
clearance, and proteinuria did not differ significantly be-
tween patients with versus without AGPN during a 36-
month follow up4 data which are consistent with our results.
In summarizing, we underline that UTIs are a frequent
problem after RTx. Their most common form is AB. E coli
and E faecium are the predominant pathogens. Female
gender and exposure to greater degrees of immunosuppres-
sion due to ARE or CMV infection are risk factors for UTI.
Vesicoureteral reflux or strictures at the ureterovesical
junction are risk factors for recurrent UTIs. Recognizing a
risk factor allows for a more rapid diagnosis among patients
with predisposing characteristics. Because Enterococcus spp
is a predominant pathogen during first month after RTx, we
should consider introducing another antibiotic into periop-
erative prophylaxis, which would act against these bacteria
or would not promote their growth. However, defining
appropriate antibiotic prophylaxis against most causative
agents without selecting resistant strains is difficult for
patients with impaired renal function exposed at the same
time to a variety of medications due to the risk of a adverse
interactions.
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